Hacker News Reader

Comment by nradov | Hacker News Reader

If something is unsustainable then eventually it will stop. US healthcare costs have been increasing at faster than the rate of inflation to the extent that it now consumes about 18% of GDP. The majority of people are on employer sponsored group health plans and employers have absorbed most of the cost increases but they're reaching a breaking point. I predict that more employers will simply drop medical benefits and choose to pay the penalty instead, forcing employees to purchase their own health plans on state ACA exchanges.

https://www.kff.org/affordable-care-act/employer-responsibil...

View on HN

ACA plans are going up even more on average than employer based plans, at the same time subsidies are being reduced.

The ACA exchanges are possibly doomed long term. People on that skew mid to lower income (but higher than medicaid), and many won't be able to afford the higher premiums - so they will drop off. So then there is the death spiral situation.

That's the insurers putting their finger on the scale so they can hold out for their employment health insurance scam.

I'd prefer that if it was replaced by a system where the business pays/subsidizes YOUR ACA plan. Changing health plans when you change jobs is a huge headache.

I'd prefer it be unrelated and they can just pay me a fucking salary without deducting several tens-of-thousands "for my benefit".

Don't opt in to the health insurance from your employer then.

I'm obligated to purchase a 30K lottery ticket and lose year over year on the chance I get cancer.

You just described insurance as a whole. If you truly just want catastrophic coverage, get a dirt cheap catastrophic coverage plan from the marketplace and pay for meds and basic care out of pocket, you'll probably save money.

Your employer will not pass any savings on to employees. When has that EVER happened in modern history?

You will be taking a shadow pay cut instead. Or soooo much worse, they will cut your healthcare benefits, and instead pay you the balance of your portion of the premium, which isn't even close to what health benefits cost, and they will angrily expect you to thank them for the privilege.

Then the market would adjust and offer a rebate for not requiring insurance. You can make any claims against that but then you'd have to say something akin to "there is no market for employees". The money that my employer pays in premiums as indicated on my w2 must be going to the insurer surely, even if they are self-insured? If its going to a pool that my employer just gets to keep then why is that tax deductible and why would I trust them with my health insurance?

On the face of it, +1 and yes please, but only if we also see a push to get more/better ACA plans on the market. In some states the pickings are quite slim; last time I browsed ACA plans there were no PPO plans, for example.

I would also accept Medicare For All if we're shooting big here :)

A better solution to untie employment from health insurance would be to make premiums tax deductible. That way you would no longer be financially penalized for opting out of employer provided coverage. The cost would be no different than the pre-tax dollars the employer used to pay.

True but it would also be more of a hassle and would be subject to things like putting it in competition with the standard deduction, which doesn't seem to have happened with employer withholdings.

That would be awesome, especially if we could get rid of the yearly Open Enrollment period. We could finally dump insurance providers that don't provide good service or who have bad networks without having to change jobs.

And in the years it would take for a new system to shake out of this disruption and chaos, most people would be unable to access healthcare for basically anything.

Isn't that just great?

I too would love to disconnect healthcare from employment, but good god is this the wrong way to do it. But the current administration has shown for over 20 years that it is utterly incapable of building a solution, so they will just keep tearing down what little of this system is effective while pocketing billions.

If you had 20k extra in your pocket to cover regular shit and 10k to pay for a private health insurance covering catastrophic shit all the while regular hospital expenses went down (cough diagnosis, broken bones, etc etc) I think that would be a good thing. Right now you can see the effects of taking insurance out of the system by going to private practice that doesn't accept insurance. These fuckers way overstepped, not only are you paying several 10K for insurance you pay more when you go for minor issues.

I can't speak to smaller employers who actually use the insurance capability, but larger employers (e.g. 500+ employees) are almost certainly self-insured. They bring the money for the loss pool and use the insurance company for claims service and network.

On it's face it might seem like this isn't related to your complaint, but one of the consequences of self-insurance is that the employer essentially has a dial that they can turn that influences what level of service you get from the provider. If the pool is okay, then your employer might spring for additional benefits like free telehealth. If the pool is marginal, they might force you into a pharmacy plan. And if the pool is completely hosed, then the provider can get aggressive about requiring documentation to bring pool spend back in line.

Exactly right. Many consumers naively blame their health insurance company when they have trouble with a denied claim or prior authorization. What they don't realize is that in most cases the "insurance" company isn't actually providing insurance (bearing financial risk) at all and is simply acting as a third-party administrator for a self-funded employer. It's ultimately the employer that decides what to cover (within legal limits). Insurance companies are happy to offer plans that pay 100% of every claim for everything no questions asked if that's what an employer wants.

Yes and no (and I worked for a company that built software for administrating all that).

You are right, the insurers in a sense don't care about specifics - you can say "everyone gets 52 massage visits a year covered 100%" and they'll do that for you.

But when you talk about TPAs, realize too that those self-funded employers obviously haven't done the actuarial work, so they'll by and large follow an insurer plan because that's had a lot of effort put into balance, optimization and such. Otherwise it's like "I don't know, how much -should- we pay for X?"

Sure, I understand that. Health insurers and TPAs all have standard offerings that they'll sell off the shelf to any customer that wants one. But the point is that they're happy to build a custom product with better benefits for any large customer that asks. When consumers aren't happy with their coverage it's pointless and counterproductive to complain about "greedy" insurance companies: any major improvements will have to come from employers or government. (I suspect that some large employers are secretly happy to take advantage of public ignorance and let insurers take the blame for everything.)

Of course if we take a step back it's crazy that the current system of tax incentives and penalties essentially forces most large employers to do some level of healthcare actuarial work. There's a whole niche industry of consultants who assist self-funded employers with this. But we'd all be better off if access to affordable health coverage wasn't tied to employment.

> "greedy" insurance companies: any major improvements will have to come from employers or government

Pointless blaming employers or governments - their pockets aren't unlimited.

The problem is the greedy insured.

The insured only want the best when it comes to medicine and procedures.

Infinite want for important needs is hard to deal with (our economics cannot match our morals). Part of the reason for our roundabout ways of managing healthcare is so that budgets exist at all (nobody wants their healthcare options restricted). For public healthcare in New Zealand waiting lists are used to ration procedures, and expensive drugs don't get funded.

We're not the greedy insured in the US. Your point about unlimited resources is valid.

But we spend far more, multiple times more for exactly the same medical goods andservices available in other countries, for that fraction of the price.

It'd be a great start if there was equality, before we start talking about "greedy insured".

Even more reasons for insurance companies to not exist.

Not only does what you describe introduce additional middle-man costs that aren't being spent on actual care, but it also obscures the overall health of the public, by creating a number of private health pools that are administered separately.

If we had a single payer system, we'd have much better data on spend vs outcomes and would be able to direct the flow of care much better.

"employers have absorbed most of the cost increases "

Health insurance is part of the total compensation so it's employees who have absorbed the cost by lower salary and higher deductibles, co-pays and whatever other ways insurers find to reduce their own cost.

That thinking only applies to non-essential markets. The whole reason we're in this mess is that insurers (and government/lobbyists) realized that people will never stop getting sick or hurt and that people will pay literally anything for medical care because the alternative is gruesome, horrifying, painful death.

The market simply cannot correct for this. It's just not possible. As fewer people can afford care, prices will go up to offset lost profit. The only organic correction that can happen is if so many people die that the entire economy collapses.

So yes, we'll see a decrease in hiring, a decrease in the number of insured and/or healthy workers, and absolutely nothing will change. The public simply cannot squeeze insurance into lowering prices, nor can businesses. Only legislation can fix this problem.

But since that seems to be ever more unlikely, the best solution is probably for the people to storm the insurance companies and put the CEOs on pikes for all of the death and destruction they've inflicted on our entire society. Democracy has utterly failed us and the only reasonable option left is incredible violence. That's the sad, sorry state that american society is left in today.

Commercial health plans already have very low profit margins, enforced by the ACA minimum medical loss ratio and competitive pressures. There's nothing much to squeeze there. If you analyze the actual cashflows, most of the money is ultimately going to things like provider wages, facilities operations, prescription drugs, and medical devices. Regardless of whether bills are paid by employers, consumers, or government, any attempt to reduce overall healthcare system costs will have to focus on those areas.

And it's horrifying that you would advocate for violence on this issue so I flagged your comment.

I don't see advocacy, I see a regretful prediction (one that I think is quite possible). The horror is being caught in this system.

Reply on news.ycombinator.com